GM Case -3
March 3rd 2023
Case scenario.....
Hi, This is Swarna Kurma, IIIrd BDS. This is an online eblog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
CASESHEET :A 27 year old man has come to hospital with complaint of Unable to walk.
CHEIF COMPLAINTS: Unable to walk like normal.
HISTORY OF PRESENT ILLNESS:
(i)The Patient has suddenly was unable to walk and he couldn't walk since 4 weeks
(ii)He was feeling the tingling sensation and sweating all over his legs after he found that he couldn't walk normally
(iii)It was then followed by pedal edema
( iv) legs became weak eventually
HISTORY OF PAST ILLNESS:
No significant past history
PERSONAL HISTORY:
Diet : Mixed
Appetite : Normal
Bowel &Bladder movements : Normal
Addictions : No addictions
Known Allergies : nil
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient is Conscious nd Co-operative
Built : Moderately built
Nourishment : Moderately nourished
Pallor : No
Icterus : No
Cyanosis : No
Clubbing : No
Lymphadenopathy : No
Edema : pedaledema previously present not now
Speech : Normal
Memory : The patient can remember
Walking : The patient couldn't walk properly ,his legs were trembling
VITALS:
Temperature: 98.6°c/f ( afebrile)
Pulse: 92 beats per minute
Respiratory rate: 16 cycles per minute
Blood pressure: 120 /90mm Hg
SPO2: 100%
PROVISIONAL DIAGNOSIS :
The patient was diagnosed with "Axonal and Secondary Demyelinating Sensory Motor Neuropathy in both Lower limbs and Denovo Hypothyroidism"
Questions:
1. How did he suddenly got affected by neural disease?
2. Do Hypothyroidism affect him ?
3.How does he get cured?